Provide your email address or if you are not comfortable with email a physical address and phone number so we can get in touch with you.<form method="post" action="http://www.emailmeform.com/fid.php?formid=437257" enctype="multipart/form-data" accept-charset="UTF-8">
<table cellpadding="2" cellspacing="0" border="0" bgcolor="#FFFFFF">
<tr>
<td>
<font face="Verdana" size="2" color="#000000">Please give us your contact info and your dogs name.  </font>
 <div style="" id="mainmsg"> </div>

</td>
</tr>
</table>

<br>

<table cellpadding="2" cellspacing="0" border="0" bgcolor="#FFFFFF">

<tr valign="top">
 <td><font face="Verdana" size="2" color="#000000">Your name address and Dogs name </font></td>
 <td><textarea name="FieldData0" cols="60" rows="10"></textarea><br> </td>
</tr>

<tr valign="top">
 <td><font face="Verdana" size="2" color="#000000">Your Email Address </font></td>
 <td><input type="text" name="FieldData1" size="30"> </td>
</tr>

<tr valign="top">
 <td><font face="Verdana" size="2" color="#000000">Subject: What catagory are you in </font></td>
 <td><select name="FieldData2"><option value="Therapy dog adopted through Adopt A Pet">Therapy dog adopted through Adopt A Pet</option><option value=" Therapy dog adopted from another rescue group "> Therapy dog adopted from another rescue group </option><option value=" Therapy dog not adopted through rescue"> Therapy dog not adopted through rescue</option></select> </td>
</tr>

<tr valign="top">
 <td><font face="Verdana" size="2" color="#000000">Please tell us your dogs story </font></td>
 <td><textarea name="FieldData3" cols="60" rows="10"></textarea><br> </td>
</tr>

<tr valign="top">
 <td><font face="Verdana" size="2" color="#000000">submit photo of dog </font></td>
 <td><input type="file" name="FieldData4" value="" size="30"> </td>
</tr>

<tr>
 <td colspan="2">
</td>
</tr>
<tr>
 <td>
 </td>
 <td align="right">
<input type="text" name="hida2" value="" maxlength="100" size="3" style="display : none;">
<input type="submit" class="btn" value="Send email" name="Submit">&nbsp; &nbsp; <input type="reset" class="btn" value="  Clear  " name="Clear"></td>
</tr>
<tr>
<td colspan=2 align="center">
<br>
</td>
</tr>
</table>

</form></body>
</html>